October 17, 2007 â The clinical presentation and management of several eating disorders in children and teens are reviewed in the October 9 Online First issue of Archives of Disease in Childhood.

"The eating disorders, anorexia nervosa, bulimia nervosa and their variants, typically develop in adolescence or early adulthood, mainly in females," write Simon G. Gowers, professor of Adolescent Psychiatry at the University of Liverpool, United Kingdom. "Despite a long history, the evidence base for effective treatments is weak and existing clinical guidelines are based on consensus views rather than strong research. Effective coordinated management of physical and psychological aspects of the disorders is crucial, but outcomes remain very variable, with adverse outcomes commonly extending into adulthood."

Anorexia nervosa carries a high morbidity and occasional mortality. It may begin at about 8 years of age, peaking at about 15 to 18 years. Self-imposed restriction of calorific foods, exercise, vomiting, or purging results in weight loss or failure to thrive. Body weight remains at least 15% below age norms, with stunted or reversed pubertal development, and delayed menarche or secondary amenorrhea.

Anorexia nervosa is usually associated with poor self-esteem, feelings of ineffectiveness, depressive and anxiety features, poor concentration, obsessional symptoms, and waning social interest.

Although bulimia nervosa seldom begins before 13 years of age, by young adulthood, prevalence is greater than that of anorexia nervosa. Bulimia nervosa is characterized by a persistent preoccupation with eating, accompanied by craving and binges. Weight is maintained in normal range by self-induced vomiting or purging. Compared with adolescents with anorexia nervosa, those with bulimia nervosa may be less perfectionistic and socially withdrawn but more apt to engage in drug and alcohol misuse.

Atypical forms of anorexia nervosa and bulimia nervosa are more prevalent than full syndrome disorders. Other clinical eating disturbances in this age group may include selective eating, as well as other phobic and obsessional disorders presenting with eating disturbances, which differ from anorexia nervosa and bulimia nervosa in core psychopathology and management.

In addition to thorough history with both patient and parents individually, and complete physical examination, assessment tools may include Child versions of the Eating Attitudes Test (ChEAT) and the Eating Disorder Examination.

"It is helpful to take an approach which is respectful and age-appropriate but recognises the role of parents in providing a developmental history, their perspective on the problem and their potential role in treatment," the author writes. "Time should be taken with the young person alone to enable a sympathetic understanding of their own point of view and a full assessment of their mental state including cognition and risk. Family, social or educational stressors which may be acting as maintaining factors should be explored."

Evaluation may include determining the extent of malnutrition and electrolyte disturbance from vomiting or purging; electrocardiogram if the patient is emaciated; tests for muscle weakness; luteinizing hormone (LH) levels and their response to LH-releasing factor; ovarian ultrasonography to evaluate ovarian maturity; and levels of growth hormone, cortisol, and insulin secretion.

Differential diagnosis may include normal dieting; hyperthyroidism, diabetes, or other physical or psychological illnesses; organic causes of diarrhea, such as idiopathic steatorrhea or inflammatory bowel disease; ovarian or pituitary disease causing amenorrhoea; or depressive and obsessional symptoms.

There are no large scale randomized controlled drug trials in anorexia nervosa at any age, but preliminary findings suggest that olanzapine may be well tolerated, resulting in weight gain, improved compliance with treatment, and decreased agitation and mealtime anxiety. A recent Cochrane review did not recommend antidepressants in anorexia nervosa.

"There is then, as yet little empirical support for the use of psychopharmacological interventions targeted at AN [anorexia nervosa] specifically," the author writes. "Nonetheless, for those with high levels of anxiety, obsessionality or mood disorder, the use of either atypical antipsychotics selective serotonin reuptake inhibitor (SSRI) antidepressants or both may be clinically useful."

However, in adults with bulimia nervosa, antidepressant drugs appear to have an "antibulimic" effect, often resulting in a rapid decline in the frequency of binge eating and purging and in improved mood.

Despite the lack of agreement regarding oral feeding requirements, weight gain goals are around 1 kg/week for inpatients and 0.5 kg/week for outpatients, with adjustment after an initial safe weight has been achieved to ensure that growth is in line with normal weight and height trajectories.

Nasogastric feeding should only be a last resort for patients who persistently refuse normal eating. Strict behavioral regimes are not effective and may be perceived by the young person as coercive, abusive, or reinforcing low self-esteem.

Clinicians must avoid inducing the refeeding syndrome, a rare, potentially fatal fluid and electrolyte disturbance that may follow sudden increases in nutritional intake in patients near starvation, especially with parenteral nutrition. Regular monitoring of vital signs and serum electrolytes, including phosphorous, glucose, magnesium, and potassium are essential.

Individual psychological therapies have little research evidence to support them. Cognitive-behavioral therapy (CBT) focuses on modifying the behavior and ways of thinking that maintain the eating disorder. CBT usually involves about 20 individual treatment sessions for 5 months and has been shown to be the most effective treatment for adults with bulimia nervosa.

Family therapy is the most studied intervention for adolescents with anorexia nervosa. This at first focuses on behavioral change around eating to promote weight gain. Parents are advised to offer support and commitment to refeeding.

Hospital admission for the severely malnourished young person allows physical health monitoring, introduction of normal eating habits, intensive psychological therapy, and respite for the family. Potential harms of admission may include disruption of schooling and family life and difficulty ensuring continuity of care after discharge.

"Recent developments have seen a growth in family based treatments and evidence-based individual therapeutic approaches, including motivational treatments," the author concludes. "Clear guidance on the most effective treatments is hampered by a lack of quality treatment studies. However a wealth of experience has contributed to valuable clinical guidelines to direct management in both a paediatric and mental health setting."

This study received no external funding, and the author has disclosed no relevant financial relationships.

Arch Dis Child. Published online October 9, 2007.

Clinical Context
Eating disorders, which comprise anorexia nervosa, bulimia nervosa, and their variants, tend to occur in adolescence or early adulthood, mainly in females. The evidence base for the efficacy of treatments is weak, with effective coordinated care recommended, but outcomes are still variable and the condition often persists into adulthood with a high morbidity.

This is a review of the clinical features and types of eating disorders and discusses pharmacologic, psychological, psychosocial, and in-hospital strategies for management.

Study Highlights
Eating disorders comprise anorexia nervosa, bulimia nervosa, and associated disorders.
Anorexia nervosa develops from age 8 years, reaching a peak at 15 to 18 years, whereas bulimia nervosa is rare for those younger than 13 years and becomes more common in adulthood.
The eating disorder syndromes comprise a range of physical, psychological, and behavioral features.
In bulimia nervosa, persistent preoccupation with food and binges are more dominant behaviors.
Cyclical bingeing and purging and missing meals is a feature of bulimia nervosa.
In anorexia nervosa, body weight is maintained at least 15% below expected, and pubertal development is stunted or reversed.
Delay in menarche or amenorrhea may occur.
In anorexia nervosa, the dominant feature is cognitive distortion with self-worth dependent on the ability to restrict food intake and there is no loss of appetite with weight loss seen as an achievement.
Dieting may be an expression of competitiveness or battle of wills, and self-induced vomiting and laxative abuse may be practiced by a subgroup.
Young persons may present with emaciation, starvation, menstrual disturbance, or dietary disturbance.
The ChEAT and the Eating Disorder Examination are screening tools that recognized parents' roles and patients' motivations.
For anorexia nervosa, the degree of malnutrition should be assessed together with electrolyte disturbance associated with vomiting and bingeing or purging.
Body mass index should be assessed against age-appropriate norms, and temperature, pulse, and blood pressure and electrocardiogram measured.
Comorbidities and differential diagnoses to be considered include obsessive-compulsive disorders or symptoms, depression, and psychotic illnesses.
There are no large scale randomized trials to demonstrate efficacy of any pharmacologic agents for anorexia nervosa.
Preliminary findings suggest that olanzapine is well tolerated and associated with weight gain and overall decrease in agitation and mealtime anxiety.
Fluoxetine may reduce the rate of relapse after inpatient management, but findings have not been replicated.
Patients with eating disorders and concurrent anxiety, obsessive-compulsive disorder, and social phobia may benefit from atypical antipsychotics or antidepressants.
For bulimia nervosa, antidepressants may be linked with a decline in frequency of binge eating and purging, but results have not been shown to be sustained.
There is a lack of consensus about refeeding requirements.
The refeeding syndrome describes a potentially life-threatening disturbance of fluid and electrolyte imbalance linked with rapid nutritional intake after starvation; close monitoring is advocated during refeeding.
Among psychological approaches, CBT, interpersonal psychotherapy, and transtheoretical models of change have been used to modify eating behaviors.
A recent emphasis on outpatient family therapy has resulted in greater evaluation of this strategy.
For inpatient management, age-appropriate facilities are recommended with active consent of patients and participation by family members.
Inpatient psychiatric care varies internationally with a combination of nutritional rehabilitation, family therapies, psychosocial rehabilitation, and psychotherapy.
Specialized day patient treatment units usually offer attendance for 4 to 7 days with supervised meals and concurrent individual, family, and medical and pharmacologic management.